A Message on COVID-19 from the WorkSTEPS Medical Team:

Using Testing to Inform Return-to-Work Decisions

With some exceptions, countries around the world are seeing the impact of policies put in place to flatten the curve. With the rate of new cases and deaths decreasing, talk of how best to ease restrictions is increasing.

A top priority among employers is how to enable a safe return to work, and many are focused on the role that Covid-19 testing can play in their overall return-to-work (RTW) strategy and in the making specific return-to-work decisions.

We have been digging deep into the research and we’re in ongoing discussions internally, with peers, and with customers to better understand the promises and limitations of testing, and to develop guidance regarding the use of testing in RTW policies and practices.

We have summarized our findings and recommendations, and can make them available upon request. Key take-aways of the document include:

• We believe testing can play an essential role in a RTW strategy, but there are many considerations to take into account, such as procurement, logistics, data privacy and communications.
• No test on the market right now will give a clear-cut infected/not infected or immune/not immune result. The tests are just not there yet.
• A comprehensive testing protocol is recommended. Where possible, use two types of tests: A) the PCR test to inform a clinical assessment for diagnosis; and B) the immunoassay test which also has diagnostic value and is primarily used to determine immunity. In the document, we provide guidance on how to use PCR and immunoassay tests to inform clinical assessment for RTW determination.
• Perhaps most critically, we recommend testing should be layered into a more comprehensive system of prevention measures. Because tests are imperfect, asymptomatic people who are sick with Covid-19 are likely to slip through, and those thought to be immune may not be. Therefore, vigilance in daily testing (temperature checks and questions), distancing and barriers, disinfection, personal hygiene and mask-wearing should be maintained.
• Companies need to remain alert to changes in testing technologies and the context of their policies, and agile to make changes that take advantage of opportunities to improve or streamline systems.

We’ve also compiled a couple of simple flow charts to guide RTW decisions with/without the use of test results, and we’re working on more comprehensive/sophisticated flow charts that will provide more specific guidance based on different test results. If you would like a copy of our findings and recommendations, a copy of the flow charts, or for additional guidance on RTW decisions, contact us here.

As always, we welcome your feedback and questions, and we encourage you to share information about how you’re using testing to inform your RTW decisions.

From our (work from home) team to yours,

Ben Hoffman, MD, MPH
Chief Medical Officer
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Tony Nigliazzo, MD
Medical Director
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Loraine Kanyare, MSN, MPH, RN
Director of Case Management
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Robert L. Levitin, MD
Physician Consultant
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Lynda Phillips, LVN
Nurse Case Manager
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Codey Church, LVN
Nurse Case Manager
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Kerry Womack, LVN
Nurse Case Manager
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Chuck Reynolds
Strategic Communications Consultant

Click here for more info on our Coronavirus Medical Hotline for Employers & Employees

Medical:

Cases globally surpassed 2 million. Some countries have begun to ease lockdowns, others brace for the worst. Total case burden and mortality have roughly doubled in 13 days and continue to grow steadily. The actual total number of cases is significantly higher since not all cases are being tested or seen in healthcare delivery systems. In the United States, inadequate testing capacity continues to prove challenging across the country.  

The US Food and Drug Administration issued an emergency use authorization for a blood purification system to treat patients 18 years of age or older with confirmed Coronavirus Disease 2019 (COVID-19) admitted to the intensive care unit (ICU) with confirmed or imminent respiratory failure.

The authorized product works by reducing the amount of cytokines and other inflammatory mediators, i.e., small active proteins in the bloodstream that control a cell’s immune response by filtering the blood and returning the filtered blood to the patient. The proteins that are removed are typically elevated during infections and can be associated with a “cytokine storm” that occurs in some COVID-19 patients, leading to severe inflammation, rapidly progressive shock, respiratory failure, organ failure and death.

The FDA issued this emergency use authorization to Terumo BCT Inc. and Marker Therapeutics AG for their Spectra Optia Apheresis System and Depuro D2000 Adsorption Cartridge devices.

In a recent study researchers suggest that not every case of infection may be contributing to immunity. Of 175 Chinese patients with mild symptoms of Covid-19, 70 percent developed strong antibody responses, but about 25 percent developed a low response and about 5 percent developed no detectable response at all. Mild illness, in other words, might not always build up protection.

The question of acquired immunity remains:

“With regards to recovery and then re-infection, I believe we do not have the answers to that. That is an unknown,” Mike Ryan, executive director of WHO’s emergencies programs, said at a press conference on Monday.

A study published late last week in Emerging Infectious Diseases found a wide distribution of COVID-19 virus genetic material on surfaces and in the air about 4 meters (13 feet) from patients in two hospital wards in Wuhan, China, posing a risk to healthcare workers.  This also confirms that significant viral particles are found in aerosol.

Investigating the peak of transmission of the COVID-19 virus, researchers observed high viral load in COVID-19 patients immediately after symptoms presented, which tapered off over a period of approximately 21 days. The researchers concluded that the viral load could potentially peak around the time symptoms present, or possibly slightly earlier. Based on the viral load data and case data from the 77 transmission events, the researchers estimated that 44% of the transmissions occurred during the index case’s pre-symptomatic period and that COVID-19 patients become infectious 2.3 days before symptom onset, with a peak in infectiousness around 0.7 days before symptom onset.

Mitigation / Suppression:

On Tuesday, President Trump announced a decision to halt funding to the World Health Organization.  The biennial budget for the WHO is about $6 billion, which comes from member countries around the world. In 2019, the last year for which figures were available, the United States contributed about $553 million.

The US Department of Health and Human Services announced that it finalized contracts with several companies to produce mechanical ventilators for the national COVID-19 response. Contracts with 5 companies were issued under the Defense Production Act (DPA), and 2 additional contracts were issued outside the scope of the DPA. Combined with previous federal ventilator contracts, US companies have committed to producing 6,190 ventilators by May 8; 29,510 by June 1; and 137,431 by the end of 2020. These units will be allocated to the Strategic National Stockpile which will then distribute them to support state-level responses. The 7 new contracts total more than US $1.4 billion.

Rutgers University researchers have received US government clearance for the first saliva test to help diagnose COVID-19, a new approach that could help expand testing options and reduce risks of infection for health care workers.

Absent other interventions, a key metric for the success of social distancing is whether critical care capacities are exceeded. To avoid this, prolonged or intermittent social distancing may be necessary into 2022. Additional interventions, including expanded critical care capacity and an effective therapeutic, would improve the success of intermittent distancing and hasten the acquisition of herd immunity. Longitudinal serological studies are urgently needed to determine the extent and duration of immunity to SARS-CoV-2. Even in the event of apparent elimination, SARS-CoV-2 surveillance should be maintained since a resurgence in contagion could be possible as late as 2024.

Corporate:

Reopening the economy will depend on companies diagnosing coronavirus cases in the workplace. As employees return to work, perhaps as early as May, employers can offer screening at their place of business. Rapid diagnosis and containment will be a critical part of limiting spread. Bringing these activities into the workplace would make them more widespread and routine and can be done in conjunction with efforts to expand testing throughout the healthcare system.

This should be part of a broader employer effort to fight respiratory illnesses in the workplace. Employers have long offered flu vaccines and passed out hand sanitizer in the winter. This coronavirus should be treated similarly, with employers invested in protecting workers. Until there is a vaccine, preventing Covid-19 outbreaks will depend mostly on testing, isolation and tracing the contacts of people who test positive. Workplace testing would catch the disease

where it spreads—especially for employees who can’t work remotely and risk infection by coming in contact with many others during the day, such as store clerks.

The CDC and FEMA have created a plan to reopen the US:

The plan lays out three phases: Preparing the nation to reopen with a national communication campaign and community readiness assessment until May 1. Then, the effort through May 15 would involve ramping up manufacturing of testing kits and personal protective equipment and increasing emergency funding. Then staged reopenings would begin, depending on local conditions. The plan does not give dates for reopenings but specified “not before May 1.”

Harvard Business Review published a proposal for getting Americans back to work. It requires the conditions below to exist before reopening a state’s economy:

• The state is over the peak of the current wave.
• Health systems in specific regions agree that they have the resources and personnel available to deal with smaller inevitable second waves of disease. Some communities may be unable to open due to capacity limitations.
• The availability of sufficient testing capability to identify both those who still have an active infection and those who have evidence of prior infection. The plan emphasized testing over temperature-taking. Taking individuals’ temperatures is inexpensive and easy to use but cannot detect asymptomatic people who may be transmitting the virus.
• The widespread availability of PPE, including protective masks, not only for health care workers but also for returning workers, along with continued practice of social distancing.

If these conditions are met, they proposed allowing people to return to work who have recovered from the virus, have demonstrable immunity, are under age 65, and have no complicating medical conditions. The first group includes those with asymptomatic and previously symptomatic patients who are now virus-free. The second includes those who test negative for current infection, a test that would need to be repeated at regular intervals. Both categories would need to be verified.